Panic Disorder and the Reasons Behind It
Everyone will experience the sensation of anxiety or fear at one time or another.
Classically, the distinction between anxiety and fear was that anxiety occurred in response to a vague threat or to a lack of an external threat, whereas fear was more intense than anxiety and only occurred in response to a tangible threatening situation. Over time, these definitions have meshed somewhat, and anxiety and fear share many commonalities. Anxiety is a term that is now often used to describe less intense manifestations of fear that are elicited in response to some perceived potential future threat.
Both the sensations of anxiety and fear are adaptive responses that are designed to warn the person of an impending threat and to prepare them to deal with such a threat by either confronting it (fight) or escaping from it (flight). Psychologists and psychiatrists that study anxiety have described three major components to the experience of anxiety:
- A cognitive component that is comprised of how the person thinks about anxiety and the anxiety-provoking situation
- A physiological component that consists of how the individual experiences the physical sensations associated with their anxiety, such as its intensity and duration
- A behavioral component that consists of the actions that the person takes in response to their experience of anxiety
Anxiety is often associated with an impulse to engage in flight or escape as opposed to direct confrontation. In clinical terms, when a person’s relationship with anxiety becomes dysfunctional, they may be diagnosed with an anxiety disorder.
What Is an Anxiety Disorder?
It is important to understand that experiencing dysfunctional levels of anxiety and/or depression is common in nearly every different type of psychological disorder listed by the American Psychiatric Association.
Just having dysfunctional levels of anxiety does not qualify as an anxiety disorder.
An anxiety disorder is diagnosed when the primary manifestation of the individual’s dysfunctional behavior is related to anxiety and when:
- The intensity of the anxiety is well out of proportion to the actual danger involved or is inappropriate given the individual’s age.
- The duration of the anxiety as well out of proportion to the actual danger involved is inappropriate given the individual’s age.
- The individual continues to experience issues with anxiety for at least six months or more.
- As a result of the issues with anxiety, the individual experiences issues with functioning, such as issues with work, in personal affairs, in personal relationships, at school, etc.
- The anxiety cannot be better explained by the presence of another mental health disorder, the use of drugs or medications, or as a result of some other medical condition, such as a thyroid condition, stroke, or head injury.
In the current conceptualization of anxiety disorders by the American Psychiatric Association, there are several different types of anxiety disorders that include phobias, generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, agoraphobia, and panic disorder.
Panic disorder is an anxiety disorder that is diagnosed when an individual experiences repeated panic attacks and then exhibits certain behavioral responses to the anticipation of experiencing further panic attacks. Recall the three components of anxiety mentioned above. For someone to have a disorder with anxiety, the person will typically manifest dysfunctional behavior related to all three components of anxiety.
Panic attacks are relatively common in the general population. Many people will experience occasional anxiety attacks, which may resemble panic attacks; however, the vast majority of people who experience these will not develop extremely dysfunctional behaviors associated with them or with anticipating future episodes of anxiety. In addition, people diagnosed with other psychiatric disorders, such as post-traumatic stress disorder, will often experience panic attacks.
Panic disorder can only be diagnosed in an individual who exhibits certain responses to having panic attacks that are considered to be out of proportion to the actual danger associated with them and/or inappropriate for the individual’s age (e.g., expectations regarding young children and responses to anxiety are much different than they are for adults). Thus, while the core symptom of panic disorder is recurrent panic attacks, the individual must also demonstrate a certain set of responses to these attacks in order to be formally diagnosed with panic disorder.
The American Psychiatric Association lists the specific symptoms that qualify for a panic attack. Formal panic attacks are defined by the presence of four or more of the specific symptoms.
While the specific separate diagnostic qualifiers for panic attacks will not be listed here, the symptoms of panic attacks include:
- Heart palpitations, or a very rapid or pounding heartbeat
- Trembling and/or shaking, numbness, tingling sensations, jitteriness, chills, or even hot flashes
- Feeling short of breath, heaviness in the chest, or chest pain, which may feel like a heart attack
- Feeling lightheaded, dizzy, or as if one is about to faint
- Feeling as if one is going to choke, having abdominal pain, or being extremely nauseous
- Feeling detached, feeling as if one is about to die, or just feeling that one is losing control
Many individuals who experience repeated panic attacks or even first-time panic attacks may think they are having a heart attack or other life-threatening condition. Panic attacks often occur without any real provocation; however, they may also occur in response to some specific situation that is anxiety-provoking to an individual. In order for someone to be diagnosed with panic disorder, in addition to having recurrent panic attacks, they must also display at least one of the following behaviors:
- Demonstrate persistent concern or worry about additional panic attacks or their consequences for the duration of at least one month
- Demonstrate a significant dysfunctional change in their behavior that is related to their experience of panic attacks, such as avoiding situations that may cause them anxiety and trigger panic attacks
For example, someone who has a panic attack at work and then stops going to work or working altogether because they fear they may experience more panic attacks at work would likely be displaying the behaviors associated with panic disorder.
The median age of onset associated with individuals diagnosed with panic disorder is 24 years old. The American Psychiatric Association reports that in a given year, 2-3 percent of the population will be diagnosed with panic disorder, and females are far more likely to be diagnosed with any anxiety disorder than males are.
There are no current identified specific causes of panic disorder; however, it is generally considered that a combination of genetic and environmental factors interact to produce the disorder. In addition, individuals who have thyroid, cardiovascular, or other medical issues will often experience extreme anxiety attacks that are diagnosed as panic attacks.
Individuals who experience panic attacks should have a full physical workup in order to rule out purely physiological causes of these experiences with intense anxiety. In cases where a cardiovascular or thyroid condition is creating the sensation of severe anxiety, a diagnosis of panic disorder would not appropriate as specified above (e.g. the panic attacks or the anxiety associated with anxiety disorders cannot be better explained by the presence of a medical condition). In these cases, addressing the physiological problem often results in the cessation of anxiety.
Panic Disorder and Substance Abuse
The American Psychiatric Association and other organizations aimed at identifying and treating mental health issues, such as the National Institute of Mental Health and the National Institute of Drug Abuse, consistently report a very high association between the diagnosis of any mental health disorder and a propensity to engage in substance abuse. While there are a number of different possible explanations for this high association, no single explanation has ever been demonstrated to be a valid description of a mental health disorder causing one to develop a substance use disorder (e.g., such as self-medicating) or a substance use disorder leading to the development of other psychological disorders.
Panic disorder is no exception to the observation that a significant number of individuals diagnosed with panic disorder are also candidates for a diagnosis of a substance use disorder. As a general rule one can expect at least 20 percent of all individuals diagnosed with panic disorder to also have a co-occurring substance use disorder, although in specific situations, this figure may be higher or lower. In many cases, individuals developed panic disorder prior to developing a substance use disorder, and in many cases, the opposite relationship has been noted. Some individuals will self-medicate with specific substances, such as alcohol, to avoid the discomfort associated with their panic attacks, but research indicates that this situation only occurs if the person actually believes that using the substance will control their panic attacks. If the person is not fully committed to this idea, they are far less likely to engage in substance abuse. Recall that a sense of loss of control is often a symptom associated with panic attacks, and individuals with panic disorder who do not feel that abusing drugs or alcohol can control their symptoms are less likely to develop substance use disorders.
Typically, individuals with anxiety disorders will abuse substances, such as alcohol, central nervous system depressants, tobacco, marijuana, and even stimulants.
An individual who is diagnosed with a co-occurring panic disorder and substance use disorder requires that both disorders be treated concurrently in order for either disorder to be successfully addressed.
Treatment for Panic Disorder
There are a number of different approaches to treating panic disorder. In addition, there are also a number of self-help and alternative treatments that are touted as effective in the treatment of panic disorder. While some of these alternative approaches may be effective in addressing issues with normal anxiety, there is often no or very weak research support that claims these approaches are effective in treating anxiety disorders such as panic disorder. The difference between the experience of normal anxiety and an anxiety disorder can be visualized as trying to compare a typical individual out for a Sunday afternoon walk to the speed of an Olympic gold medal sprinter. The intensity of the two experiences is quite different, and both issues require different approaches to address them.
Medications are often used to address panic attacks; however, there is no medication that is designed to treat panic disorder. There are a number of medications that can be used to address the symptoms of panic attacks.
- Antidepressant medications, particularly selective serotonin reuptake inhibitors like Zoloft, Paxil, and Luvox, are often used in the treatment of the panic attacks associated with panic disorder. Other classes of antidepressant medications, such as tricyclic antidepressants, may be used in specific situations, but they are now less widely used.
- Benzodiazepines are central nervous system depressant drugs used in the treatment of anxiety disorders. These include familiar drugs, such as Valium, Xanax, Ativan, and Klonopin. These drugs effectively address the symptoms of anxiety; however, they are also associated with the potential for the development of physical dependence and abuse. While they are often given to control panic attacks, they must be strictly and judiciously applied.
- BuSpar is an anti-anxiety medication that is primarily used to treat very chronic low-level anxiety, such as what occurs with general anxiety disorder. It can also be used to treat panic attacks. It lacks the severe potential for abuse and physical dependence that are observed with central nervous system depressant drugs like benzos.
- Drugs such as valproic acid (often used to treat seizures or bipolar disorder), verapamil (a drug designed to treat hypertension), and beta blockers can be used in the treatment of anxiety.
While the use of medications can effectively control the situational effects of anxiety, they do not address panic disorder. Taking these medications will typically not address the disorder, and individuals who stop taking them may soon experience panic attacks and a recurrence of their panic disorder. Instead, using psychotherapy and a combination of medication appears to be the best approach.
The psychotherapy approach of choice for panic disorder is a form of Cognitive Behavioral Therapy (CBT) that includes relaxation training, exposure techniques (individuals are trained to deal with severe anxiety via relaxation and stress control, and then exposed to situations that recreate the onset of their panic attacks, allowing them to control the anxiety), cognitive restructuring (identifying certain dysfunctional thoughts in individuals with panic disorder, and then addressing and changing these thoughts), and psychoeducation regarding the specifics of the individual’s disorder.
Treatment for panic disorder and a co-occurring substance use disorder also includes substance use disorder treatment as a component of the overall treatment plan. Typically, when co-occurring disorders are treated, the therapeutic approach is described as an integrated approach that combines several different types of therapists and physicians in a multidisciplinary approach. Both disorders are treated concurrently and also given the specific separate attention they need to be effectively addressed.